Hand-sewn Bowel Anastomosis: The Only Correct Choice. Ashok Babu, M.D. Department of Surgery University of Colorado
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1 Hand-sewn Bowel Anastomosis: The Only Correct Choice Ashok Babu, M.D. Department of Surgery University of Colorado
2 Outline History Trial data in specific applications Colorectal Ileocolic Esophagogastric Trauma Time efficiency Cost efficiency
3 History Sutureless anastomosis (compression) 1826: Donaus Hand-sewn double layer 1882: Connel Hand-sewn single layer 1887 Halsted, 1922 Schiassi, 1951 Gambee, 1975 Matheson Stapled 1908 Hungary Hultl Early 1960 s Moscow Late 1960 s USA Ravitch
4 The Controversy
5 Colorectal Meta-analysis Complication 13 PRCT comparing handsewn vs stapled Leak No study independently showed significant Mortality difference in leak rate, stricture, cancer Stricture recurrence, or mortality Tech Problem Odds Ratio Conf. Interval Cancer rec Wound infection ODDS RATIO LESS THAN 1 FAVORS STAPLED ANASTOMOSIS MacRae et. al. Dis Colon Rectum 1998.
6 Colorectal Meta-analysis Complication Cochrane Review 9 Stapled PRCT. Sewn 1233 patient CI 622 stapled Leak 611 handsewn 6.3% 7.1% NS Mortality 2.4% 3.6% NS Indications included cancer, diverticulosis, Stricture prolapse 8% 2% 1.2%- 8.1% Mostly EEA but some end to side Wound infection 5.9% 4.3% NS Lustosa et. al. Cochrane Database
7 Colorectal Summary No difference between stapled vs. handsewn except for: higher stricture and technical mishap rate in stapled Average of 8 minutes longer time for handsewn (from one study)
8 Ileocolic Very few trials Largest PRMCT by Kracht et. al. 440 patients RADIOLOGIC leak detection Randomized to side/side stapled (106) or 4 types of sutured End to end interrupted/continuous (84/77) End to side interrupted/continuous (82/91) 8.3% leak rate in all handsewn groups vs 3% stapled Not significant in subgroups Kracht et. al. Int J Colorectal Dis. 1993
9 Ileocolic Crohn s Retrospective study End to End Wide side/side Wide lumen side to side stapled (69) compared to Handsewn end to end (69) Stricture/fistula Hypothesis: wide lumen 26% leads to less 4% stasis, p=.017 pressure, and ischemia resulting in lower leak, stricture, and recurrence rates Recurrence 57% 24% p=.04 Munoz-Juarez. Dis Col Rectum. 2001
10 Ileocolic Crohn s Retrospective study Wide lumen side to side stapled (71) compared to Handsewn end to end (55) Leak Rate 14.1% end to end vs 2% (p=0.02) Resegotti. Dis Col Rectum
11 Ileocolic Summary These studies compare anastomotic configuration AND stapled vs. handsewn technique simultaneously This makes the data uninterpretable
12 Esophagogastric anastomosis Meta-analysis 5 PRCT s Circular stapler vs. end-end hand-sewn All patients underwent esophagectomy for cancer and randomized to 2 techniques No significant difference in leak or stricture rate, though trend in favor of hand-sewn RR Mortality 0.45 in hand-sewn (p=0.05)
13 Trauma Suture is better Retrospective cohort Harborview, Seattle Small bowel and large bowel, blunt and penet. Hypothesis: bowel edema in trauma renders fixed depth staple dangerous Looked for clinically significant leaks Stapled Sewn p n Leak 4 (7%) 0.04 IAA 6 (10%) 2 (3%).13 Fistula 1 1 Brundage et. al. JOT 1999
14 Trauma Suture is better Retrospective multicenter Small bowel and large bowel, blunt and penet. Stapled Sewn p n Leak IAA Fistula 3 2 NS Brundage et. al. JOT 2001
15 Trauma No Difference Retrospective cohort Minnesota group Small bowel injury only, blunt and penet. Compared resections with handsewn vs. stapled reconstruction Stapled Sewn p n Leak 0 3 NS IAA NS Fistula 2 0 NS Witzke et. al. JOT 2000
16 Trauma No Difference Prospective multicenter nonrandomized Penetrating colon injuries Leaks defined as req. draining or operation Stapled Sewn p n Infection 26.6% 20.3% 0.3 IAA 20.3% 15.6% 0.39 Leak 6.3% 7.8% 0.69 Mortality 3.8% 3.1% 0.8 Demetriades, Moore et. al. JOT 2002
17 Shape Technique Technical Location Indication Heterogeneity Stapled Handsewn End-to-End End-to-Side Side-to-Side Circular Linear Continuous Interrupted Tension Blood Supply Technical execution Esophagus Stomach Small bowel Large bowel Cancer IBD Trauma Infection 2 nd layer No reinforcement Single Layer Double Layer
18 Operative Time 1 st Author Design n Stapled (min) Sewn (min) George PRCT Didolkar PRCT McGinn PRCT Scher PNRT Adloff Retro
19 Single surgeon experience Bruno Cola, Bologna, Italy
20 Cola. It. J Coloproct Cost Analysis (Euros)
21 Cola. It. J Coloproct Cost Analysis (Euros)
22 Conclusion No solid evidence for improved outcomes or decreased operative times with stapled anastomosis of any type In an era of morbidly expensive healthcare, the use of staplers for GI anastomosis should ONLY be considered in the setting of special circumstance (laparoscopy, etc.)
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